Category Archives: Lean Hospital

I like this quote because it touches on a couple of other ideas I have read before. One author I like (Joiner) states that all leaders need to treat decisions as experiments. Lean challenges HiPPOs (Highest Paid Persons Opinion) to use data in decision making instead of through assertiveness or by being charismatic. The quote below is a good reminder to always experiment with theories to be able to show data if the theory is true or not. It also helps me really notice when opinions are made verses asking for objective data to support.

“In a world without data, opinion prevails…Most managerial dictums are hypotheses. A hypothesis by nature is useless unless proven by data…Asserting an opinion as a fact is a lot easier. Pretending that our assuredness reflects objective truth is certainly convenient …we need to test our beliefs against data…Managers must see themselves as experimenters who lead learning, not dictators who impose control.” – Peter Scholtes “The Leader’s Handbook pages 29,33

“Beliefs, behaviors, assumptions, and attitudes do not change through study, conferences, seminars, and training classes; they change through repeated action. This is not dissimilar to breaking unhealthy habits such as smoking or overeating. The consistently repeated lean actions and restraint from doing old non-lean things are undoubtedly ‘painful’ in the beginning” (source: The Kaizen Event Fieldbook by Hamel pages 61-62)

Have you dreamed of eating the Grove Café’s world famous pancakes or been lucky enough to try them yourself? What? You never heard of them before now? It almost sounds like a classic Onion article.

Many hospitals aspire to be “World Class” but there is no measure to know if they succeed at it. Just like the pancakes, only that hospital seems to define themselves as achieving that level of success. For that matter, I am not sure what would make them stand out with that definition since a Google search of “world class” and hospital returned 47,300,000 results.

Do patients choose a hospital based on a world class definition? Similarly, do local “top doctor” magazines drive patients to hospitals or is the US NEWS” Top Hospitals” issue a key deciding factor (despite its questionable criteria)?

I would worry about achieving the level of “World Class” (whatever that actually means) since being at the top of a benchmark usually does not inspire people to improve once attained.

I think a better mission for hospitals is to strive for “perfect care”. Patients deserve predictable clinical outcomes and they shouldn’t get harmed or sicker by being in a hospital. Patients want better customer service and should not have to experience any unnecessary waits. Lastly, healthcare should have a fair and reasonable price for their co-pay and insurance.

Hospitals need to ask their patients if they want to be treated at someplace famous or where they will receive perfect care. If forced to choose one over the other, which would they pick? Focusing on the means (providing perfect care) will help hospitals achieve outcome of being deemed world class.

I learned a lot at the recent Lean Healthcare Transformation Summit and will blog my reflections from it. The first thing that stands out to me was the consistent effort leaders were making to walk the talk. I think the list below is a great start of what will help leaders help transform and sustain their organizations.

Go see, ask why, show respect, and learn

Practice respect for people as individuals, engage their heads & hearts, and don’t shame or blame.

Be humble

Lead as though you have no authority

Teach and ask questions

Persevere

Experiment

Be inclusive of everyone

Be free from the “smartest society” trap and don’t fear appearing to be outed as incompetent

I often see restaurants and other businesses with signs outside advertising “Under New Management” and wonder why they need to advertise this to potential customers. It got me to thinking how Lean success requires new management as well to be successful.

I think local businesses hang announcements about a leadership change because they want to tell customers they will receive better service than before. Maybe they now offer better quality, improved customer service, superior product selection, friendlier employees because they are happier, safer conditions, or a combination of all. Lean transformations provide similar benefits but they require new management to achieve them.

The leadership team might be the same people as before, but their management practices will need to change. Remember, improved results were not being created and sustained under an old management model.

Below is not a comprehensive list, but here are some of the changes to traditional leadership:

Decisions are made based on data and observation, not just charisma and intuition

Leaders act as coaches and teachers to develop people to solve problems deeper in the organization instead of being the one to solve them

The voice of the customer is primary focus

Standardized work is followed by leaders and not just those in production

Credibility is earned by practicing Lean and not just sponsoring it or speaking positively about it

Ability to fire-fight is not a sign of great Lean leaders; removing root causes to prevent fires shows lean competency

Use long-term thinking for selecting activities and strategies

Practice Respect For People for all staff, customers, suppliers, and other stakeholders

Manage both the means and results by understanding how processes produce outcomes

Becoming “under new management” is not an easy task but it will help your organization remain competitive in the years to come.

I was pretty excited to come across this “Make Healthcare Better” SlideShare presentation from Drew Weilage (RSS readers may need to click link to view). His message of focusing on the patient and moving away from mediocrity in hospitals is exactly the mission I have. I think Lean helps hospitals work to make things convenient for the patient and not just the provider. I hope you find this interesting as well. He also has a blog that is worth checking out.

This presentation really fires me up about what I do and the potential for hospitals. I love the ending line: “Good is not good enough”.

Technology can sometimes seem like the right way to address issues but most people do not know about the extra problems it can create. You may get a short-term win with technology but end up suffering in the long-term.

If your hospital or organization in on a Lean journey, technology can sometimes go against your philosophy and management system.

Here are some things to consider if you are looking at technology:

Never automate a bad process. Eliminate waste and understand what the process really needs before you find a way to make it faster. Quicker waste is still waste.

IT systems should fit the process, not the other way around. In The Birth Of Lean, there was an early Toyota document with the following: “It is not a conveyor that operates men…it is men that operate a conveyor…” So often people change processes to meet the rigidity of the technology. Ensure the technology does not force standardization that has waste, lowers quality, or makes no sense.

Be able to make changes after it is implemented. So often organizations are stuck with wasteful systems because nobody has knowledge to make iterative improvements or the cost to bring someone in is so high that nobody fixes it until it is totally broke.

Trial first instead of piloting. Pilots usually happen after you buy the system. I have rarely seen organizations stop implementation if a pilot does not work out like they expected. Organizations usually just change their messaging and training to fit what the technology can do instead of ensuring it does what they wanted it to do. Trialing is part of PDCA thinking and will help ensure the IT system meets the needs of the process without being financially committed to rolling it out.

Know the problem you are addressing. With today’s technology, there are all sorts of bells and whistles that seem great. Although impressive, the added features may be more than needed (overprocessing waste) and can sometimes distract from why you were looking for technology. These ‘extras’ can also add complexity to your processes.

I think technology can be embraced in Lean organizations but it is important to ensure it is thoroughly tested, reliable, and improvable before you commit to implementing.

“On The Mend” by John Toussaint, Roger Gerard, and Emily Adams is highly recommended for any level of leader in a hospital.

The authors stress the importance of how leaders need to change themselves in a Lean transformation. Insights to the thinking of leaders at ThedaCare will challenge a hospital’s current management approach and hopefully inspire experimentation of a new style.

Woven throughout the book is the continual discussion of the impacts of a shame and blame culture. The authors discuss some of the root causes of shame and blame. They explain some of the counter-measures they used to improve the culture. There is a whole chapter on engaging doctors that is of value for any healthcare leader.

The book greatly shows how time reduction is not only a productivity metric, but how timeliness impacts the health and safety of the patient. Other examples throughout the book demonstrate that Lean can make great improvements in a hospital.

I appreciate the credibility of the authors. Many times, they state when things did not work well, how they were the problem in some cases, and how they would approach differently in the future. I think it is important for these sort of books to be honest since a Lean journey is not easy. “On The Mend” provides a realistic look at how this kind of thinking can make lasting transformation in hospitals.

More information about the book including videos, author interviews, and a free chapter available at L.E.I.

Disclosure: A review copy of this book was provided to me by the publisher.

Does your hospital have a system to ensure nurses have working equipment or they know how to get them fixed?

I recently visited a hospital where the answer would be “NO”.

Last week, a family member needed a day surgery procedure done at a local hospital. There were signs in the prep/recovery room touting their move to electronic medical records and no longer needing paper charts. The problem for the nurse was, the Computer On Wheels (C.O.W.) did not work. The nurse was unable to access or update the electronic chart!

A second nurse came in during the morning before the procedure to try to troubleshoot the malfunctioning C.O.W. It was decided to grab a C.O.W. from another room and use it instead. I am not sure if other nurses had to search for the missing C.O.W. now that it has been moved into our room where it sat there for four hours. A third nurse eventually pulled it away to put back where it belonged.

The first nurse came back in and tried to access the original C.O.W. in our room and commented “This still doesn’t work yet?”

I looked at the C.O.W. and there was no signage about how to troubleshoot or who to call. I do not know if a nurse tried calling their helpdesk out of my view but it looked like nobody knew what to do with the broken computer. It seemed like nobody knew who was to take charge in fixing it. One can almost infer they expected it to magically fix itself!

Three nurses spent time reacting to faulty equipment that could have been better used providing care to patients. Instead of spending their creativity solving patient issues, they use it creating workarounds.

Lean thinking can help hospitals put systems into place to ensure equipment always works. Procedures can be created for what to do when something is broken and how to handle. Make things visual so staff doesn’t have to rely on memory or look up procedures because instructions are attached to the item being used.

Helping remove waste and frustration from those giving care with make a better experience for those receiving care.

I define communication as two-way where input and feedback is requested and announcements as one-way “this is coming or it’s already here” kind of messages.

Announcements are not an effective way to bring your organization along on your Lean journey. People feel done-to or it appears as though they have no voice. Announcements give the impression of very top-down leadership even if you had some of the front-line staff involved in creating the change (intent versus impact).

For people to be engaged in the change, ensure you are seeking input and feedback from those affected. Firstly, before you make a change or set a target condition you should have gone and seen the actual process. Use this time in gemba to get feedback about the problem. I have seen flipchart paper put in an area for staff to add input prior to developing counter-measures to trial. Use staff meetings to ask for thoughts before you start improving.

When developing counter-measures, share ideas with stakeholders or involve them in the trial. Ask them what works or what further adjustments should be made before it becomes the new standard work. Their input will make a better counter-measure and help them be invested the change.

After the standard work gets implemented, have leadership and key coaches on the floor soliciting feedback and providing clarifications. The counter-measure may have some missing pieces that are only discovered after “launch” or people may not understand it enough to follow it. This communication helps your organization sustain the improvement.

Honestly look at your “communication” strategy. Is it really just announcements or are you actively asking for feedback to be seriously considered? Did you bump the communication discussion from every agenda and now stuck in the mode of announcing because a counter-measure is developed and ready to go?

I had an experience recently to renew my excitement to help transform hospitals with Lean. Our son’s pediatrician is helping us deal with his colic. The doctor said he wants to try one change at a time to determine what will help my boy. This is Plan-Do-Check-Act!

Some organizations want to implement a ton of stuff at once. If the problem is fixed, it is difficult to pinpoint which of the myriad of countermeasures did the trick. If the problem is not fixed, they throw a bunch more changes to the wall to see what sticks.

Our pediatrician patiently tries one thing at a time. Once the issue is resolved, he will then begin removing some of the counter-measures (medication and other soothing techniques) and continue to check that the colic is still gone. How often do organizations remove some of the counter-measures after they implement a bunch at once?

PDCA is scientific thinking and doctors use it. My excitement is renewed because I see how using PDCA with providers will help make Lean relevant for them in hospitals.

I am now back from my wonderful 4.5 weeks of paternity leave and am more committed than ever to help hospitals become lean. Through the birth and follow-up pediatrician visits, I have been a customer of health care and see many opportunities for staff and patient satisfaction. Here are some of the things I experienced:

New IV Ports – One nurse had trouble connecting an IV port on my wife during labor. She exclaimed “they changed our ports a few months ago but we kept on using the old ones. Now the old ports have been thrown away and we are forced to use the new ones. I don’t see why they switched them.” Another RN mentioned the ports later and said “I was on vacation when the ports changed so I never got the training for how to use them”.

Lack Of Patient Centered Care – Our OB seemed to have an agenda on the day of labor and increased medications without telling us first despite our birth plan and previous conversations requesting informed consent for things like this. The OB was using scare tactics to push for a c-section without explaining pros and cons for alternatives.

Pediatrician Office Visit Late – For our one month check-up the pediatrician was 20 minutes late. The doctor looked visibly flustered and distracted. He apologized for running late and expressed how bad he feels to be running behind and hates to make people wait.

What Is Up With Our Hospital Bill? – The day before we discharged, a person provided an estimated amount and asked for a credit card. A month later we get a bill in the mail for half the amount we already paid without any indication our initial payment was credited towards anything. I called their billing customer support only to be told the initial credit card amount was applied later in the day that my bill was mailed. The rep told me the lower bill we got in the mail was incorrect and we really owed the larger amount we originally paid for with a credit card (plus an additional $68).

Lean transformations can help each of these situations. Using better training, job instruction sheets, and explaining why would help the nurses with their ports (although I question what prompted the change if they were allowed to use the old ports for a few months if someone claimed safety was the reason). Helping providers understand what their patient’s wants and needs are will allow them to better serve their community and will most likely help with growth. Doctors can have reduced stress and better engagement if the root causes for being late for appointments are improved. Lastly, recognition that the patient experience usually ends once everything is paid can help improve billing accuracy/clarity and save money from rework due to patients calling in to ask about their bill.

With renewed energy and passion I return to work to help those in hospitals see the opportunities all around them while providing guidance for how to capitalize on them.

Lost In The Land Of Firefighting – This short video shows how we can easily lose sight when putting out fires. I think it also shows why gemba walks need to be done instead of those doing the work saying “I already know it because I do it everyday”.

An Idea Is Not Always Enough – Jamie Flinchbaugh uses an Aesop fable to demonstrate the importance of taking action on an idea instead of just talking about it.

Of 777s and Heart Rate Monitors – Mark Graban tells a story about a hospital death due to a heart monitor being turned off and illustrating the need for error-proofing.

My wife and I are excitedly expecting our first son around the beginning of April. I am getting a first hand experience of what it is like to be a “customer” of a hospital experience and it makes me realize how Lean can really help.

Effects of on-call: My wife’s OB advised that she can not guarantee she will be the one to deliver our child due to the fact that the little boy can arrive at any time of the day (understandable). There are 4 other doctors that would be covering for her if she is not available and we would have to schedule appointments if we wanted to meet them prior. As a customer, this adds a complexity and I would prefer a reduced number of on-calls. It would waste the other doctor’s times to meet with us if they did not end up being on-call on birth night. Design the pathway to be simple for the patient.

Potential rushing: One thing that concerns me is the notion of doctors pushing the birth faster to fit their schedules. I am not sure how true it is, but from interviewing doulas and recent moms, some C-sections are given because the provider has other things to do or wants to go home (two cases as described to me). Our OB said the other day she might do a procedure “to speed things up”. If the patient chooses options to make things faster or it is needed for the health of the mom & baby – go for it. If the hospital system is not flexible enough to allow births to take a natural course (if patient chooses) and requires speeding up artificially, improvement is needed for staffing and room utilization to ensure you are providing value to patients.

Unpredictability and non-standardized: From conversations it appears as though every experience changes greatly on which nurse you get that day and your provider. Babies and the human body are unpredictable and cause variation but some things CAN be standardized. As a customer, I would feel more confident if it was explained to me that the hospital has a generally predictable practice and have plans in place if the mom shows specific signs. Unpredictability is problamatic too from an insurance perspective since the hospital can not tell us who the expected roles will be to ensure each are covered so we can make an informed choice. As a customer, I would chose a hospital with standardized work over an organization who just tells me “it depends”.

As a hospital customer, are my demands unreasonable? If you work at a hospital, what are your customers wanting? Do you agree or disagree with me that Lean thinking can help the hospital meet my needs?